Jan 8 2018 – Dementia Case
Download Document: Case Recommendations Jan 8 2018
Date: January 8 2018
PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise establish a provider-patient relationship between any ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.
The patient is a 49 year old woman with frontotemporal dementia and significant behavioural issues. The case presenter requested a review of her behaviour management and pharmacotherapies.
Summary of Recommendations:
- Pain management: May consider reassessment of pain-neuropathic/post herpetic neuralgia, muscular, osteoarthritis (Resources below: PAINAD, Abbey pain scale, DOS charting, Research study Pain vs antipsychotic link )
- Recommend Trial of Regularly administered Acetaminophen to start
- May consider increasing Nortriptyline for neuropathic pain, with caution re: risk of delirium with increased anticholinergic load
- May also consider augmentation with gaba/pregabalin or retrial of low dose narcotic such as hydromorphone
- Alternatively may consider nabilone but evidence in dementia not evidenced based at this time
- May consider the patient’s behavior as having components of a compulsive disorder, thus may consider Imipramine instead of Nortriptyline, noting potential side effects .
- Hx of Bipolar disorder: may consider trial of Carbamazepine, good evidence that it can be effective with behaviours, however several drug interactions.
- Venlafaxine can be more activating, may consider tapering.
- Review Goals Of Care and Quality Of Life : Rosuvastatin and calcium may be of no benefit particularly if Rosuvastatin is being used for primary prevention, may consider discontinuing to decrease pill burden.
- Non-pharmacological interventions:
- Individualized toileting schedule, increased mobilization less time in the gerichair, baby gates on doorways, TV programs she enjoyed on infinite loop
- Stimulus response: May consider positively reinforcing the behavior you want (does she have a favorite food that could be used for this).
- Social Support: Friendly visiting program, volunteers.
- Caregiver supports – Referral of family to caregiver support group and/or education around benefits of their visits. For younger children see Resources below: NICE website, “When Dementia is in the House”.
1. DOS Tool
https://www.mdcalc.com/pain-assessment-advanced-dementia-scale-painad – online calculator
3. Abbey Pain Scale
http://prc.coh.org/PainNOA/Abbey_Tool.pdf – printable
https://www.mdcalc.com/abbey-pain-scale-dementia-patients – online calculator
4. When Dementia is in the House
http://www.nicenet.ca/files/WDH_Tool_WEB.pdf – printable
5. Carbamazepine for tx of bipolar disorder:
6. Pain management in patients with dementia:
7. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial: